insurance.arkansas

1. www.insurance.arkansas.gov Arkansas Insurance Department

2. Arkansas Insurance Department The primary mission is consumer protection through insurer solvency and market conduct regulation, and fraud prosecution and deterrence. 

3. Insurance Department Divisions • Administration • Accounting • Consumer Services • Consumer Assistance Program • Criminal Investigations • Finance • Human Resources • Legal • License • Health Benefits Exchange • Health Insurance Premium Rate Review • Liquidation • Life and Health • Property and Casualty • Public Employee Claims • Risk Management • Senior Health Insurance Information Program

4. Consumer Services Division Stats • Toll-free Phone 1-800-852-5494 • Assisted Arkansans in collecting $14,006,232 • Received 2,864 consumer complaints • Closed 3,164 consumer complaint files • Responded to 19,207 telephone inquiries and assisted 299 walk-in consumers • Participated in 130 dislocated worker workshops and 28 expos and health fairs

5. SHIIP Stats • Assist Arkansans with all things MEDICARE • Assisted more than 14,500 Medicare recipients or caregivers • 6,642 Part D comparisons of which 2,648 assisted with enrollment • 2,132 Medigap comparison and eligibility • 2,008 Medicare Advantage comparisons

6. Complaints • Contact Insurance Plan/Carrier first and ask for clarification • Insurance Department Complaints • Claims payment concerns • Agent misconduct • Medicare Supplement Policy • Medicare Complaints via SHIIP • Claims Payment Issues Plan False or Misleading Sales & Marketing Practices

7. Patient Protection and Affordable Care Act (PPACA)

8. Affordable Care Act Changes • Take Care Arkansas • Temporary (until 2014) high-risk pool for those with pre-existing conditions • Administered by Blue Cross Blue Shield • 1-800-285-6477 • WWW.TAKECAREARKANSAS.ORG • Early Retirees (before age 65) • Temporary program to offset cost of retiree coverage paid to employers (not retirees)

9. Affordable Care Act & Medicare • Annual Election Period • EARLIER starts Oct 15 and ends Dec 7 • Medicare Claims • Maximum period for submission of Medicare claims reduced time period • Not more than 12 months • Preventive Services • No longer pay Part B deductible and coinsurance for most preventative services

11. Affordable Care Act- Medicare • Therapy caps extended • Physical & Speech pathology= combined $1,860 per year • Occupational therapy= $1,860 per year

12. Affordable Care Act- Medicare • Power-driven wheelchairs effective Jan 2011 • Medicare no longer purchase with lump-sum • Paid over 13-month period • Increased ground ambulance rates retroactive to Jan 2010: 3% rural, 2% urban • Hospice Reform effective Nov 2011 • Face-to-face encounter is required with hospice physician or nurse practitioner

13. Affordable Care Act –MA Plans • MA Plans can not charge more than Original Medicare • Services: chemotherapy, skilled nursing facility, dialysis, etc. • Payments to MA frozen in 2011 • MA Disenrollment Period Jan 1-Feb 14 • Leave MA and go to Original Medicare with stand alone Part D

14. Affordable Care Act- Part D • Donut Hole in 2012 • 50% discount on brand name drugs • 14% discount on generic drugs • Higher income people pay higher Part D premium • Effective Jan 2011 • Same thresholds as Part B premium • Modified Adjusted Gross Income • Income reported on IRS tax return 2 years ago

15. Centers for Disease Control and Prevention reports less than 10% of Medicare beneficiaries receive all recommended screenings and immunizations. Medicare Preventive Services • SESSION TOPICS • What is covered • Why preventive services are important • Who is eligible • How much you pay

16. Medicare Preventive Services • Medicare coverage based on • Age • Gender • Medical history • Covered by • Part B of Original Medicare • Medicare Advantage and other Medicare plans Medicare Preventive Services

17. Covered Screening and Preventive Services • One time “Welcome to Medicare” physical exam • Physical Exam (yearly “Wellness Exam”) • Abdominal aortic aneurysm screening* • Bone mass measurement • Cardiovascular disease screenings • Colorectal cancer screenings • Diabetes screenings • EKG Screening* • Flu shots • Glaucoma tests • Hepatitis B shots • HIV Screening • Mammograms (screening) • Pap test/pelvic exam/clinical breast exam • Prostate cancer screening • Pneumococcal shots • Smoking cessation Health Reform Section4103 *When referred during Welcome to Medicare physical exam Medicare Preventive Services

18. Elimination of Part B Deductible and Coinsurance Requirements in 2011 Health Reform Section 4104 • Starting January 1, 2011 • You pay nothing for most preventive services • If you get them from a doctor or other health care provider who accepts assignment • Services affected must have an “A” or “B” rating • By the United States Preventive Services Task Force • http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm Medicare Preventive Services

19. One Time “Welcome to Medicare” Physical Exam • Covered within first 12 months of having Part B • Height, weight and body mass index • Blood pressure and end of life planning • Education, counseling, and referrals (e.g., EKG) • In Original Medicare pay • No deductible or copayment starting January 1, 2011 Changes in 2011 Medicare Preventive Services

20. Abdominal Aortic Aneurysm Screening • Abdominal aortic aneurysms (weak area bulges) • Risk factors include • A family history of abdominal aortic aneurysms • Men age 65 to 75 who have smoked at least 100 cigarettes in their lifetime • Ultrasound screening covered by Medicare • Referral from the “Welcome to Medicare” physical exam • Pay 20% of the Medicare-approved amount with no Part B deductible • No deductible or copayment starting January 1, 2011 Changes in 2011 Medicare Preventive Services

21. New Annual Wellness Visit Health Reform Section 4103 • Effective January 1, 2011 • Annual Wellness Visit • Comprehensive health risk assessment • Personalized prevention plan • Health advice and referral to education and preventive counseling • No copayment or deductible • Available every 12 months (after first 12 months of initial Part B coverage) • But not within 12 months of receiving either a “Welcome to Medicare” physical exam or another Annual Wellness visit Medicare Preventive Services

22. Bone Mass Measurement • Covered if at risk for osteoporosis • Every 2 years (more often if medically necessary) • Risk factors include but aren’t limited to • Age 50 or older • Female • Family or personal history of broken bones • White or Asian • In Original Medicare pay • No deductible or copayment starting • January 1, 2011 Changes in 2011 Medicare Preventive Services

23. Cardiovascular Disease Screening • Blood test for early detection • Heart disease • Stroke • Tests for levels of • Cholesterol • Triglycerides • Lipids • Covered every 5 years • In Original Medicare you pay nothing Medicare Preventive Services

24. Cardiac Rehabilitation • Medicare covers cardiac programs that include • Exercise • Education • Counseling certain patients with a doctor’s referral • Intensive cardiac rehabilitation programs • In Original Medicare, pay 20% of the Medicare-approved amount • If you get the services in a doctor’s office • No change in 2011, is not rated “A” or “B” • Pay a copayment in a hospital outpatient setting Medicare Preventive Services

25. Colorectal Cancer Screening • Helps find precancerous growths • Helps prevent or find cancer early • One or more of the following tests may be covered • Fecal Occult Blood Test • Flexible Sigmoidoscopy • Colonoscopy • Barium Enema Medicare Preventive Services

26. Medicare Preventive Services

27. Diabetes Risk Factors • Diabetes is a chronic condition • Body does not produce or properly use insulin • Risk Factors • High blood pressure • High cholesterol • Obesity • History of high blood sugar • At least two of the following • Age 65 or older, • Overweight, • Family history of diabetes, or • Past gestational diabetes or having a baby over 9 pounds Medicare Preventive Services

28. Diabetes Management • May be able to avoid or delay complications • Manage diabetes • Test blood sugar regularly • Eat a proper diet • Exercise regularly • Take medication as prescribed Medicare Preventive Services

29. Diabetes Screening • Testing for people at risk • Includes fasting blood glucose test • Talk with your doctor about frequency • Got pre-diabetes, then screening up to twice in a 12-month period • Not diagnosed or pre-diabetic, then screening once in 12-month period • In Original Medicare pay • No deductible or coinsurance Medicare Preventive Services

30. Covered Diabetes Services • Screening for all at risk • For people with diabetes (need prescription) • Self-management training • Medical nutrition therapy • Blood sugar testing supplies • Lancets, monitors, testing strips= Part B • Insulin, syringes, needles, alcohol swabs, gauze = Part D • Special eye exams • Hemoglobin A1c tests Medicare Preventive Services

31. Covered Diabetes Services • People with diabetes who need them • Insulin pumps • Special foot care • Therapeutic shoes • In Original Medicare pay • 20% after Part B deductible • No change in 2011 • Medicare Coverage of Diabetes Supplies & Services (CMS Pub. 11022) Medicare Preventive Services

32. Glaucoma Examination • Glaucoma is caused by increased eye pressure • May gradually lose sight without symptoms • Protect yourself with screening eye exam • Covered if high risk once every 12 months • High-risk= Family history, African American and age 50 or old, or Hispanic and age 65 or older • In Original Medicare pay • 20% of the Medicare-approved amount • Part B deductible applies for the doctor services • A copayment in a hospital outpatient setting • No change in 2011 Medicare Preventive Services

33. HIV Screening • Medicare covers HIV screening for people • Who are pregnant or at increased risk for the infection • Includes anyone who asks for the test • Covered once every 12 months • Up to 3 times during a pregnancy • In Original Medicare pay • Generally pay 20% of the Medicare-approved amount for the doctor’s visit • No deductible or copayment for the test • No change in 2011 Medicare Preventive Services

34. Pap Test and Pelvic Exam with Clinical Breast Exam • Risk factors for some cancers in woman include • Had an Abnormal Pap test • Infected with Human papilloma virus (HPV) • Began sexuality activity before age 16 • Had many sexual partners • Medicare covers • Pap test to help find cervical and vaginal cancer • Screening pelvic exam to help find fibroids/ovarian cancers • Clinical breast exam (another way to look for breast cancer) Medicare Preventive Services

35. Pap Test and Pelvic Exam with Clinical Breast Exam • Covered for all women with Medicare • Once every 24 months for most women • Once every 12 months if • At high risk for cervical or vaginal cancer • Childbearing age and abnormal Pap test in the past 36 months Medicare Preventive Services

36. Pap Test and Pelvic Exam with Clinical Breast Exam • In Original Medicare pay nothing • Nothing for Pap lab test • No Part B deductible • No copayment starting January 1, 2011 Health Reform Section 4104 Medicare Preventive Services

37. Prostate Cancer Risks • Risk increases with age • Age 45 – 1 in 2,500 • Age 50 – 1 in 476 • Age 55 – 1 in 120 • Age 60 – 1 in 43 • Age 65 – 1 in 21 • Age 70 – 1 in 13 • Age 75 – 1 in 9 • Ethnicity risk: AA, White, Hispanic at highest risk • Hereditary risk Medicare Preventive Services

38. Prostate Cancer Screening • Covered • For all men with Medicare • Beginning the day after 50th birthday • Tests include • Digital rectal exam • PSA blood test • Prostate-specific antigen • In Original Medicare pay • Nothing for the PSA blood (lab) test • 20% after Part B deductible for digital rectal exam • No change in 2011 Medicare Preventive Services

39. Breast Cancer and Mammography • Breast cancer in women in U.S. • Most commonly diagnosed non-skin cancer • Second leading cause of cancer death • Risk increases with age • Successfully treated when found early • Mammogram • Checks for abnormal breast tissue • Coverage includes digital technology Medicare Preventive Services

40. Screening Mammogram Health Reform Section 4104 • Covered for all women with Medicare • One baseline mammogram age 35 to 39 • Once a year starting at age 40 • In Original Medicare pay nothing • No Part B deductible • No deductible or copayment starting January 1, 2011 Changes in 2011 Medicare Preventive Services

41. Diagnostic Mammogram • Used when there are clinical findings • On physical exam • Abnormal screening mammogram • Medicare covers as many as needed • Also covered for men • Different payment rates if diagnostic mammograms • Usually pay 20% of Medicare approved amount and Part B deductible applies Medicare Preventive Services

42. Smoking Cessation • Quitting gives significant health benefits • Even older adults who smoked for years • When services are covered • If you have an illness caused or complicated by tobacco use • Includes smokers with heart or lung disease, stroke, multiple cancers, weak bones, blood clots, or cataracts • If you take medication affected by tobacco use • Such as insulin, medication for high blood pressure, blood clots, and depression Medicare Preventive Services

43. Smoking Cessation Services • Cessation counseling • Up to 8 sessions per year • Inpatient or outpatient • Intermediate or intensive • In Original Medicare pay • 20% after Part B deductible • No change in 2011 • Medicare Part D prescription drug coverage • Can help pay for drug therapy • Nicotine patches, for example Medicare Preventive Services

44. Influenza (“Flu”) Shot • Flu can lead to pneumonia • Can be dangerous for people 50 and over • Flu viruses are always changing • Shot updated for most current flu viruses • Recommended in fall or winter (Oct or Nov) • Flu shot covered for all people with Medicare • Once each flu season protects for about a year • In Original Medicare pay • No deductible or copayment Medicare Preventive Services

45. H1N1 Flu Vaccine • H1N1 flu is caused by a new strain of influenza virus • Risk factors not as high for those over 65 • Higher risk for those with certain disabilities • Medicare covers administration of the H1N1 flu shot • You can’t be charged for the vaccine (providers get it free) • You pay nothing if provider accepts assignment • Part B deductible and coinsurance don’t apply • To the vaccine or its administration • You should still get the seasonal flu shot Medicare Preventive Services

46. Pneumococcal Pneumonia Shot • Pneumonia is inflammation in the lungs • Caused by bacteria (streptococcus pneumoniae) • One shot could be all you ever need • All people with Medicare are eligible • In Original Medicare pay nothing • No deductible or copayment Medicare Preventive Services

47. Hepatitis B Shots Health Reform Section 4104 • Serious disease (virus attacks the liver) • Can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, or death • Covered for medium to high risk • End-stage renal disease and hemophilia • Condition that lowers resistance to infection • In Original Medicare pay nothing • No deductible or copayment starting January 1, 2011 Changes in 2011 Medicare Preventive Services

48. Medicare Education Benefit • People with Stage IV chronic kidney disease • Have advanced kidney damage and • Will likely need dialysis or a kidney transplant soon • Medicare Part B covers • Up to six sessions of kidney disease education services if have stage IV and doctor refers for the service • Provided to help prevent or delay the need for dialysis • Pay 20% of the Medicare-approved amount, and the Part B deductible applies • No change in 2011 Medicare Preventive Services

49. Protecting the Medicare Trust Funds • Centers for Medicare & Medicaid Services (CMS) has to balance how to • Pay claims on time vs. conduct reviews • Prevent/detect fraud vs. limit burden on providers • CMS must protect the Trust Funds • Medicare Hospital Insurance Trust Fund (Part A) • Supplementary Medical Insurance Trust Fund (Part B)